Dr. Meng-Sheng Lin, L.Ac.

Dr. Meng-sheng Lin Acupuncture Center

2007 N. Collins Blvd. Suite 307, Richardson, TX 75080

Tel/Fax: (972)644-2608 Email:

Website: www.dallasacupuncturecenter.com

PATIENT HISTORY

Patient’s Name: Last______First______Middle______

Chief Complaint: ______Date: ______

Name of last physician seen for this complaint: ______

Date of last examination: ______Diagnosis: ______

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Test(s) performed: ______

______

______

Treatment(s) received: ______

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Please list current medication/herbs or medical treatment you are taking:

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______

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Please list any operations you have had and the dates of surgery:

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______

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______

______

______

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Please list all allergies:

Inhalant: ______

Topical: ______

Foods: ______

Medication: ______

Please list all major injuries (example: fractures, concussion, etc) and the dates of injury:

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______

______

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CHECK IF YOU SUFFER FROM ANY OF THE LIST BELOW:

ABDOMINAL PAIN / HIGH BLOOD PRESSURE
ALCOHOLISM / HIP PAIN
ALLERGIES / HYPERTHYROIDISM
ANEMIA / HYPOGLYCEMIA
ANGINA / HYPOTHYROIDISM
APNEA / INCONTINENCE
ARM PAIN / INFERTILITY
ARTHRITIS / INSOMNIA
ASTHMA / KNEE PAIN
BACK PAIN / LEG PAIN
BACK PAIN, LOWER / MENSTRUAL IRREGULARITY
BRONCHITIS / MENSTRUAL PAIN
BURSITIS / MIGRAINES
CANDIDIOSIS / NECK PAIN
CANCER / NEUROMA
CARPAL TUNNEL SYNDROME / NUMBNESS
CHOLESTEROL, HIGH / OSTEOARTHRITIS
CIRCULATION PROBLEMS / OSTEOPOROSIS
COLITIS/ DIARRHEA / OSTEOSCLEROSIS
CONSTIPATION / PARALYSIS
DEPRESSION / PARKINSON’S
DIABETES / PHLEBITIS
DISC DISORDER, CERVICAL / PNEUMONIA
DISC DISORDER, THORACIE / RHEUMATOID ARTHRITIS
DISC DISORDER, LUMBAR / SCIATICA
EARACHE / SCLEROSIS
EDENA / SEIZURES/ CONVULSIONS
ELBOW PAIN / SHOULDER PAIN
EMPHYSEMA / SLEEPNESSNESS
ENCEPHALITIS / SKIN INFECTION
ENDOMETRIOSIS / SPONDYLOSIS
EPILEPSY / STENOSIS
FATIGUE, CHRONIC / TENDONITIS
FIBROMYALGIA / TINNITUS
FLU / T.M.J.
FOOT PAIN / TINGLING
HEADACHES / TRIGEMINAL NEURALGIA
HEPATITIS / TREMORS
HIV / TWITCHES
HERNIA / VERTIGO

NOTICE TO THE PATIENT

Pursuant to the requirements of title 3, sec. 205.301(a) (1) of TX OCC code governing the

Practice of acupuncture.

I, (patient’s name)______, am notifying the acupuncturist(s), Dr.Meng-Sheng Lin L.Ac., of the following:

Name of Primary Care Physician: ______

- Last Visit Date to PCP: ______

- Referred by PCP? Y / N

Are you currently under another physician’s care? Yes No

If yes, for: ______

I am seeking treatment at the Acupuncture Center for the following condition:

____________

I have been evaluated by a physician(MD/DO) or dentist for the condition being treated within 12 months before receiving acupuncture treatment.

Initial of patient______Date: ______

To be completed by patient, if no initial above, attesting that the Acupuncturist has referred him/her to a physician as pursuant to the requirement of sec. 205.301(b), title 3, TX OCC code governing the practice of acupuncture. I recognize that I should be evaluated by a physician (MD/DO) or dentist for the condition being treated by the acupuncturist. This serves as a referral by the acupuncturist for me to see a physician. It is my responsibility and choice whether to follow his or her advice.

Patient’s signature______Date______

Pursuant to the requirements of title 3, sec.205.301(a)(2)(c) of TX OCC code governing the practice of acupuncture:

I have received a referral from my CHIROPRACTOR within the last 30 days for acupuncture? Yes No

After being referred by a chiropractor, if after 30 days or 20 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician, and consider this written notice a referral in advance. It is my responsibility and choice whether to follow this advice.

Patient’s Signature ______Date______

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